Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, February 29, 2008

Don't Worry, Heal Happy

On a pass through Kevin MD's website a while ago, I saw a reference to an article which reported a study on anger and healing. The report, at BBC online, said, in part:

"The Brain Behavior and Immunity study indicates stress has a major impact on the body's ability to repair itself. Nearly 100 participants were asked to rate how well they could control their temper, and the speed at which they recovered from a blister was monitored. Hotheads were more than four times likely to take more than four days to heal than mild-mannered counterparts.... The team at Ohio State University gave participants blisters on one of their arms and then monitored how the wound healed over the course of eight days. They were asked to fill in a questionnaire which looked at how anger was expressed - whether externally, by shouting at others, for instance, or internally, when one rages insides but keeps a cool exterior."

At the end of the article, there was this:

"Steve Bloom, professor of metabolic medicine at Imperial College, London, said stress was now increasingly recognized as a factor in recovery rates. "Your body prioritises and sorts one thing out at a time, so if you are stressed - angry in this case - your body works through that before it gets on with the process of healing. We've yet to see a study that categorically proves having an attentive, calming presence by your bedside actually speeds up your recovery, but the evidence is certainly pointing that way." (My emphasis.)"

Studies like these (judging emotion) are a little squishy, and one might well challenge the methodology, not to mention that "prioritises" deduction. But it sorta kinda rings true, off the top of my head. Naturally, I extrapolated. I think there's an important message; or at least there might be.

I often heard from nurses on the surgical floor that my patients were calm and positive when they arrived, and that they seemed to do better than those of other surgeons. (No, I can't say it wasn't just a way to ingratiate -- for all I know, they said it to every surgeon.) Of course, I loved hearing it; it went to a very specific aim and belief of mine. If their assessment was true -- and this is me saying it was -- it validates an overt effort on my part to achieve a sense of comfort and confidence, a positive attitude toward recovery. I've always thought it makes a difference. (I recognize the article in question doesn't draw an outright conclusion. "Pointing that way," is what it says.) (Nor, let it be said, am I talking about "cure." Just recovery from surgery.)

The antithesis is the doctor -- any type, really, but in this context a surgeon -- who makes hospital rounds, perfunctorily pokes and prods and leaves with little or no meaningful communication, ignoring obvious concerns. Having watched such behavior while visiting hospitalized friends and relatives, I can say it leaves the patient and family angry and frustrated, which, this info would suggest, is actually medically counterproductive. Doctors can't, of course, remain a "calming presence by the bedside" for more than a very few minutes at a time; but we can listen, explain, even sit down and look the patient in the eye. Not only is it the human and natural way to behave, if it produces the opposite of anger, it looks like it might actually be medicinal! Even grumpy docs give antibiotics when needed. In the same spirit, maybe they'll work to provide a decent dose of needed nice.

21 comments:

I'd take it one step beyond the notion of the surgeon's bedside manner and explore the nature and the forces which bear upon the therapeutic patient relationship. Patients and families also experience fear (body image alteration, function, social role function, mortality, dependence, etc.), loss of control and potentially hopelessness. A professional relationship, whatever the duration, that is built on mutual trust, transparency of accurate communication, and on the part of the professional - dependability of presence (as opposed to perceived abandonment) is critical to allow patients to recover. This is one reason that I am so opposed to payment based on efficieny of treatment - the assembly line approach, if you will. It not only doesn't reimburse the physician or other provider for time to develop and maintain a therapeutic relationship, but it somehow infers that such a relationship is illegitimate and not worthy of payment or recognition. An entire generation of physicians and nurses has been educated and grown up in the practice arena of prospective payment, critical lack of access to health services and rewards for efficiency and economy to the detriment of the therapeutic patient relationship. This will be difficult to reverse, if indeed, it is possible.

And one more thing: making patients bear incredible costs, I believe, directly interferes with their ability to recover, convalesce and heal. When they are trying to survive, let alone recover, by continuing to go to work sick, injured and ill, trying to negotiate claims denials and appeals, trying to pay for health care out of pocket, on credit cards and by mortgaging their assets, this is perverted and undermines health. Patients shouldn't have to - and they can't - advocate and negotiate for their own care while healing. It's removing the legitimate sick role, and it harms and increases mortality rates. For the pragmatists, this means that the available worker pool is becoming sicker, more vulnerable and less productive. Not good from any perspective.

Annie: your final point is an excellent one. How nice it'd be if one could swipe a card and that would be that. I do indeed know the stresses involved in wading through all the forms and frustrations while trying to recover.

Well put doc. As a physician, we have privileged access to the trusted intimacies of patients and too often there's a tendency to concentrate too much on vital signs and the way an incision looks and whether or not the patient is pooping. Stop and listen to your patients every once on a while and it's amazing the enriching detail you find. I have an old guy in hospital now for a problem with a feeding tube; not a big deal, going home today. I asked him what he used to do for a living as I was adjusting the dressing and he said math professor. Then he proceeded to give quite an entertaining, almost metaphysical, treatise on the nature of calculus and the beauty of its logic. I actually sat down in the chair for ten minutes without saying a word. It was fascinating. When he was done, he was done. Just sort of petered out (86 years old, dysphagia from a stroke, unable to eat without aspirating). I shook his hand and left. It isn't just a transaction when doctors and patients interact; it's our lives we share...

Dr. Schwab,Truly, a wonderful post. With the number of surgeries I've had, the doctor's attitude is the make or break factor in my recovery. I have more faith in my doctor and in his treatment for me with his confidence, empathy, and kindness.

I agree with everything you said in this post. After having several surgeries, I know that my doc's attitudes play a big part. But, like you said, I also see it in other specialties, besides surgery. Mainly with oncologists. I have had two, the first was very positive and he actually would not allow you to get down. He worked very hard to stay positive and so therefore I stayed positive. The one I have now, not so much of a positive person. He always looks and acts negative, he never seems to word things in a positive manner, even when the news is really not so bad. I always leave his office feeling depressed. But, I have noticed he is this way with everyone, and none of his patients ever look happy.

Thank you for bringing up the communication aspect of healing. Maybe you can answer a question that has bugged the crap out of me for some time, being a surgical patient veteran. Why do so many docs rely soley on tests now instead of listening to what their patients are telling them?

I've had a dozen (or more?) laparascopic surgeries and an open TAH with a butcher gynecologist. With the exception of the TAH, every lap was at my insistence after all tests, scans, imagings, you-name-it were negative. I was right to insist on a look-see in every case: gallbladder, appendix, endometriosis, massive adhesions and repeated SBOs.

Jen: in med school it was said that if you don't know what's going on in your patient after a good history and physical (ie, asking the right questions and listening to the answers, among other things), there's a good chance you never will. I think it's true that, increasingly, there's a tendency to rely more on tests, and the reasons are many. I don't think (or at least I hope) that "most" doctors don't listen to their patients well enough. On the other hand, it's likely true that we could all do a better job of it.

Sid, this post does a great job of highlighting that the ways we humans heal aren't solely dependent upon medicine and surgery. There truly is a mind/body connection and both have to be fed. This is why Reiki has been so effective in the numerous hospitals around the US due to its calming and soothing affects on patients.

Lynn: Although I'm not familiar with the data on Reiki in hospitals, I think you're right, in the sense that most of the value of "alternative" or "complementary" methods is in the human contact. Which is to say, on the one hand, that the methods per se have no intrinsic special benefit; and on the other, that they may be positive because they are a way for increasing good will and attitude.

The above comment from jb resonates with me, since I've found myself in a similar situation: referred to a surgeon by family doctor because the surgeon is highly skilled, but then being warned that he has a 'tolerable' bedside manner - i.e., terrible. And that warning was accurate.

It's as if patients are forced to make a choice - see a surgeon who has a decent bedside manner but lackluster skills, or see a surgeon who has excellent technical skills, but lackluster bedside manner. The assumption seems to be that skills and manner are mutually exclusive if one wants them both to be on the higher end of the scale at the same time.

What if anything are surgical residents taught about bedside manner, if I may ask? Is the subject discussed at all? Is it discussed in terms of influencing recovery? Or is it assumed that a patient's recovery is a process wholely dependent on a surgeon's technical skills, therefore bedside manner is an extraneous nicety, and no more.

anonymous: may I humbly -- HUMBLY!!!! -- suggest that the two are not mutually exclusive. As to your question about training, I can't speak for the present day. But, sadly, I'd say it wasn't much of a consideration in my day. But may I humbly....

With my second child I had to have a c-section. I was so sick during and after the surgery. My OB was great to me, but with me something wasn't right. I was later diagnosed with post-partum depression. With my third child we were prepared for it. No problems (re: depression). I can tell you that there was a big difference in my recovery the third time around. Even though both times I was sick aferwards. I even had weird things happen the third time ( reaction to medication...tried to claw my eyes out, oh yeah!! I felt that damn bovie during surgery!!! My OB (calm man) was yelling at the anesthesiologist. I told that woman something wasn't right. that's another story). Needless to say my mood was so much better the last time and I recovered much quicker. The only thing I bitched about was to my husband (surgeon). "I hope to God that when you leave here at 5a.m. you kindly warm your hands, gently wake the patient before you start poking them in the stomach. Because if I could have gotten up I would have punched that resident in the face!"

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What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.